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Medical Nutrition Education (MNE) has been identified as an area with potential public health impact. Despite countries having distinctive education systems, barriers and facilitators to effective MNE are consistent across borders, demanding a common platform to initiate global programmes. A shared approach to supporting greater MNE is ideal to support countries to work together. In an effort to initiate this process, the Need for Nutrition Education/Innovation Programme group, in association with their strategic partners, hosted the inaugural International Summit on Medical Nutrition Education and Research on August 8, 2015 in Cambridge, UK. Speakers from the UK, the USA, Canada, Australia, New Zealand, Italy, and India provided insights into their respective countries including their education systems, inherent challenges, and potential solutions across two main themes: (1) Medical Nutrition Education, focused on best practice examples in competencies and assessment; and (2) Medical Nutrition Research, discussing how to translate nutrition research into education opportunities. The Summit identified shared needs across regions, showcased examples of transferrable strategies and identified opportunities for collaboration in nutrition education for healthcare (including medical) professionals. These proceedings highlight the key messages presented at the Summit and showcase opportunities for working together towards a common goal of improvement in MNE to improve public health at large.

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In 1995 and in 1998 the University of North Carolina at Chapel Hill received R25 grant support to create interactive CD-ROMs for teaching nutrition and nutritional biochemistry to medical students, the Nutrition In Medicine (NIM) series. Seven of the proposed ten titles have been created. Three series (Disease, Lifecycle, and Special Topics in Nutrition) teach nutrition concepts using computer-aided instruction (CAI) with emphasis on interactive learning. Patient cases with television-quality interactive videos allow students to apply nutrition knowledge to clinical problems. Pop quizzes, text-based interactions, and multiple-choice examinations help the student self-evaluate progress via immediate feedback. Educators using the programs get instructional support and updates through a dedicated Web site, printed material, telephone support, e-mail, and CD-ROM-based computer programs. Implementation at medical and osteopathic schools is continuously surveyed through questionnaires and follow-up telephone interviews. By 1999, 120 of 137 eligible U.S. medical schools owned copies of NIM CAI programs, of which 76 indicated that they were currently implementing the programs.

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Despite awareness of the importance of nutrition as part of medical student's education, numerous barriers exist to incorporating nutrition education into the medical school curriculum. Chief among such barriers is that most medical schools do not have faculty trained specifically in nutrition. A curriculum is needed that can deliver comprehensive nutrition information that is consistent across medical schools. One way to deliver this information is to use computer-assisted instruction (CAI). To meet the different needs of medical schools and provide a consistent base of nutrition information, we developed a series of interactive, multimedia educational programs (Nutrition in Medicine) that teach the basic principles of nutritional science and apply those principles in a case-oriented approach. Curriculum content is derived from the American Society for Clinical Nutrition consensus guidelines. These modules offer the advantages of accessibility, self-paced study, interactivity, immediate feedback, and tracking of student performance. Modules are distributed free to all US medical schools. Preliminary data from surveys gathered by our team at the University of North Carolina at Chapel Hill indicate that 73 US medical schools use, or are planning to use, these modules; more schools are currently evaluating the programs. Successful implementation of CAI requires easy program access, faculty training, adequate technical support, and faculty commitment to the programs as a valuable resource. CAI fails when the program is just placed in the library and students are told to use it when they can find the time.

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BACKGROUND: Computer-based instruction has been introduced at the University of North Carolina at Chapel Hill to augment its nutrition course for first-year medical students. Seven program modules have been completed; 2 more are planned. Each module explains the biochemistry and physiology of nutrition through interactive lessons, exercises, and a video case study. OBJECTIVE: The goal of this study was to evaluate the instructional efficacy and acceptability of the nutrition and cancer module when used by first-year medical students. DESIGN: The module was used by 163 first-year medical students at the university's medical school as an obligatory component of the nutrition course. Before and after using the module, students were asked to answer multiple-choice questions concerning their knowledge and attitudes; each question had 5 possible answers. RESULTS: On average, students spent approximately 3 h studying the lessons. The percentage of correct responses to 20 knowledge questions increased from 22% before the module was used to 86% immediately after its use. When a randomly selected subsample of 25% of the students took the same test 3 mo later, they answered 62% of the questions correctly. The increase in the percentage of students who felt prepared to provide advice regarding nutrition's role in cancer prevention (from 5.7% to 66.9%) suggested a successful subjective learning experience. Neither the students' initial level of interest in cancer nutrition nor their acceptance of computer-based instruction was related to learning outcome. CONCLUSIONS: The tested module is a useful and effective aid for teaching nutritional principles of cancer prevention. The evaluation strategy helped identify areas for instructional improvement.

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OBJECTIVES: This study evaluated the iron sufficiency of the Russian diet. METHODS: Data were obtained from 24-hour dietary recalls conducted in 4 rounds (1992 through 1994) of a nationally representative longitudinal survey of 10,548 women and children. Iron bioavailability was estimated via algorithms adjusting for enhancers (heme, vitamin C) and inhibitors (tannins in tea, phytates in grains) consumed at the same meal. RESULTS: Dietary iron intakes were deficient in the most vulnerable groups: young children and women of reproductive age. Poverty status was strongly associated with deficiency. After adjustment for enhancers and inhibitors, estimated bioavailable iron intakes at 3% to 4% of total iron were inadequate in all women and children. CONCLUSIONS: These dietary data suggest that Russian women and children are at high risk of iron deficiency. Grain products rich in phytates, which inhibit absorption, were the major food source of iron in Russia. High intakes of tea and low consumption of vitamin C also inhibited iron bioavailability. Since changes in eating behavior could potentially double iron bioavailability, educational programs should be explored as a strategy for improving iron nutriture.

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This investigation of 219 hemodialysis patients relates the history and prospective risk of bone fractures to apolipoprotein E (apoE) genotype. A greater percentage of the 41 patients with the E3/4 and E4/4 genotypes than of the 38 patients with the E2/3 and E2/2 genotypes had a history of bone fractures at the time of recruitment (44% versus 16%, P < 0.005). During the 4 years following recruitment, more of the patients with apoE genotypes E3/4 and E4/4 than with apoE genotypes E2/3 and E2/2 suffered bone fractures, but this difference was not statistically significant (17.1 versus 5.3%, P < 0.1). ApoE genotype appears to be an important genetic risk factor for bone fracture, possibly due to its previously reported influence on vitamin K concentrations in blood.

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This investigation of 68 hemodialysis patients (ages 33 to 91) analyzed the association of biochemical indicators of vitamin K nutriture and bone metabolism, and related both to past bone fracture history and prospective bone fracture risk. Phylloquinone concentrations were significantly lower in the 23 patients with previous fractures compared to those without (0.93 vs. 1.50 nmol/liter, P < 0.003) and a smaller percentage of their serum osteocalcin was carboxylated (48.8 vs. 53.6%, P < 0.03). The 41 patients who never had fractures had nearly three times higher phylloquinone concentrations than the nine patients with fractures during a four-year follow-up period (1.59 vs. 0.55 nmol/liter, P < 0.002) and more carboxylated serum osteocalcin (55.2 vs. 42.0%, P < 0.01). None of the patients with phylloquinone concentrations over 2.2 nmol/liter had elevated intact parathyroid hormone (iPTH) concentrations, and only patients with less than 1 nmol/liter phylloquinone had severe hyperparathyroidism (iPTH > 300 ng/liter). Our data thus indicate that suboptimal vitamin K nutriture in hemodialysis patients is associated both with increased bone fracture risk and with a high prevalence of hyperparathyroidism.

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Vitamin K occurs in nature as a series of compounds with a common 2-methyl- 1,4 naphthoquinone nucleus and differing isoprenoid side chains at the 3 position. They comprise a single major plant form, phylloquinone with a phytyl side chain and a family of bacterially synthesized menaquinones (MKs) with multiprenyl side chains. The major dietary source to humans is phylloquinone for which the chief food contributors are green, leafy vegetables followed by certain vegetable oils (soybean, rapeseed and olive oils). Recent analyses by high pressure liquid chromatography are now providing a wide-ranging database of phylloquinone in foods. Menaquinones are found in moderate concentrations in only a few foods such as cheeses (MK-8 and MK-9). A wider spectrum of MKs is synthesized by the gut microflora, and their intestinal absorption probably accounts for most of the hepatic stores, particularly those with very long side chains (MKs-10--13) synthesized by members of the genus Bacteroides. The site of absorption of floral MKs is not known, but reasonable concentrations are found in the terminal ileum where bile salt-mediated absorption is possible. Both phylloquinone and menaquinones are bioactive in hepatic gamma-carboxylation but long-chain MKs are less well absorbed. Liver stores of vitamin K are relatively small and predominantly MKs-7--13. The hepatic reserves of phylloquinone (approximately 10% of the total) are labile and turn over at a faster rate than menaquinones. Trabecular and cortical bone appear to contain substantial concentrations of both phylloquinone and menaquinones. A majority (approximately 60-70%) of the daily dietary intake of phylloquinone is lost to the body by excretion, which emphasizes the need for a continuous dietary supply to maintain tissue reserves.

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Molecules with vitamin K activity are important for optimal bone health. The major compound of this group in bone is vitamin K1 (phylloquinone), which is derived exclusively from plant foods in the diet. Vitamin K1 is absorbed along with dietary fat from the small intestine and transported by chylomicrons in blood. In serum obtained after an overnight fast from healthy men more than half of the vitamin K1 was recovered from the density fraction that contains chylomicrons and chylomicron remnants (CR), and only a quarter was associated with the major lipoprotein in serum, low density lipoprotein. The concentration of vitamin K1 in serum is closely related to the triglyceride concentration. Another determinant of vitamin K1 concentration in serum is the presence of specific variants of apolipoprotein E (apoE). ApoE is a small protein through which the vitamin K-rich CR bind to lipoprotein receptors. The three most common variants of apoE promote CR clearance from circulation with very different efficiency, in the order E2>E3>E4. The variant that promotes CR clearance best is associated with low vitamin K1 concentration in serum and increased response to vitamin K antagonists. Vitamin K1 concentration in serum is linked to vitamin K status of bone. The bone protein osteocalcin tends to be less completely carboxylated in people with low vitamin K concentrations in serum. Many hemodialysis patients with a history of bone fractures have indications of poor vitamin K status. The same patients also appear to have a greatly increased prospective bone fracture risk.

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Intra- and interindividual variation of phylloquinone (vitamin K1) concentrations was investigated by repeat analysis of serum from 28 hemodialysis patients with different apolipoprotein E genotypes. Phylloquinone concentrations ranged from 0.1 to 9.0 nM, with a mean of 1.08 nM (standard deviation 1.90 nM). Most of the variation in serum phylloquinone concentrations was due to differences between patients; the ratio of intra- to interindividual variation was 0.17. Serum triglyceride concentrations and apoE genotype together accounted for 64% of interindividual variation; in contrast, only 6% of intraindividual variation could be attributed to differences in triglyceride concentrations. The small residual variance implies that different phylloquinone consumption levels contributed relatively little to the variation of serum concentrations ( < 36% of interindividual variance). The results suggest that individual disposition is a more important determinant of serum phylloquinone concentrations than dietary phylloquinone intake.

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In the United States, adipose tissue is rarely used as a medium for assessment of prior exposures in epidemiologic studies. Adipose tissue aspirations are in general less invasive and carry less risk than phlebotomy. Tissue samples can be analyzed for a wide number of epidemiologically important exposures. Beyond reflecting long-term energy balance, this tissue offers a relatively stable depot of triglyceride and fat-soluble substances, such as fat-soluble vitamins, and pesticides. As a tissue it represents the greatest reservoir of carotenoids in the body. Halogenated hydrocarbons may be measured in concentrations of hundreds-fold greater than those in blood of the same individuals. The composition of adipose tissue also reflects the long-term dietary intakes of a number of essential fatty acids. The turnover times of all of these substances in adipose tissue remain under-researched. Sampling and storage of adipose tissue, homogeneity of sampling sites, turnover times, and the effects of diet, age, gender, race, hormones, and disease on adipose tissue composition are discussed in this review of current knowledge about adipose tissue stability. Experience in the use of adipose tissue sampling in epidemiologic studies in various countries has shown that it is simple to conduct, requires little training, carries little risk, and does not result in excessive participant refusal.

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Data from a representative health and nutrition survey of German adults (sample of 1073 women and 806 men) were used to investigate the relationship between coffee consumption and the concentration of cholesterol in serum as well as other lipoprotein constituents. For these outcome variables multivariate analyses were conducted separately for men and women. Differences in age, body mass index, smoking habits, use of oral contraceptives, physical activity, alcohol, fish, fat, milk and tea consumption were controlled for in the models. Interactions between coffee drinking behavior and smoking habits as well as between coffee and the use of oral contraceptives in their relationship with serum cholesterol were of special interest in the analyses. Higher coffee intake (> 400 ml/d) showed higher total cholesterol, LDL cholesterol and lower triglyceride rich lipoprotein (TRL) and triglyceride concentrations in serum compared to lower intake (< 200 ml/d). Smoking appeared to be an aggravating factor in these relationships. Results of the linear regression analysis demonstrated an increase of 1.66 mg/dL LDL-C per cup of coffee daily consumed for men and of 1.58 mg/dL for women. The combination of high coffee intake, smoking and no oral contraceptive use ever was associated with the highest total and LDL-C and lowest TRL concentrations in this population. The observed differences may be explained by an increase of lipoprotein lipase activity due to coffee consumption.

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Measurement of alpha-tocopherol concentrations circulating either in plasma or serum is the most common method of measuring the vitamin E status in men. The analytical determination with a suitable HPLC method produces precise and reliable results. The interpretation of the measured alpha-tocopherol values is complicated by the strong positive correlation with different blood lipids. A considerable misinterpretation of the data will occur if these confounding factors are not taken into account by a suitable adjustment. Different methods have been described in the literature which tried to control the confounding effect of blood lipids. These methods were not completely satisfying. Therefore, a mathematical regression model, based on residuals, is introduced and applied to the data of the VERA-study (Verbundstudie Ernährungserhebung und Risikofaktoren Analytik) and the consequences of the lipid-adjustment of the tocopherol values are studied in further statistical procedures. Thereafter, lipid-adjusted tocopherol concentrations can be subjected to more extensive statistical evaluations without the requirement of special stratification.

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Plasma concentrations of phylloquinone in 42 fasting hemodialysis patients showed a much wider range than in healthy adults. Phylloquinone concentrations were best predicted by the concentration ratio of beta-very-low-density-lipoprotein to low-density-lipoprotein cholesterol (r = 0.71), which is closely related to chylomicron-remnant clearance. Phylloquinone concentrations in plasma were related to apolipoprotein E genotype in the order E2 > E3 > E4. The percentage of carboxylated osteocalcin (HBC) was related to the plasma concentration of phylloquinone in patients with the apolipoprotein E genotype E3/3 (r = 0.52, P < 0.05), and in patients with the genotypes E2/3 and E2/2 (r = 0.23, P < 0.1). Overall, plasma triglyceride concentration was a better predictor for HBC than was the plasma concentration of phylloquinone. These results point to the overriding importance of chylomicrons for the transport of phylloquinone to liver and bone. Delivery to osteocalcin-producing osteoblasts seemed impaired in patients with the low receptor-affinity apolipoprotein variant E2, suggesting a major role of receptor-mediated chylomicron-remnant uptake in the transport of phylloquinone to bone.

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We present a new method for analysis of haemoglobin variants in immobilized pH gradients. The isoelectric fractionation is performed in polyacrylamide gels with copolymerized pH gradients between pH 7.0 and 8.0. The common haemoglobin variants (HbA, HbF, HbS, HbC, HbE and HbA2) are clearly resolved within this pH range. The high resolving power and reproducibility of immobilized pH gradients combined with extremely short separation times make this fractionation technique superior to all electrokinetic procedures used for haemoglobin analysis. At present, isoelectric focusing in immobilized pH gradients is a complementary tool for haemoglobin analysis when classical electrophoretic techniques do not provide sufficient resolution. We hope that in the future this technique will gain the popularity it deserves.

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For the identification of apolipoprotein E isomorphic phenotypes, fresh or thawed serum was analyzed without prior delipidation or other pretreatment. Using 5% polyacrylamide gels with a 40 mm interelectrode distance, the isoforms were separated by isoelectric focusing in immobilized pH gradients ranging from pH 5 to 6.5, and transferred onto polyvinylidene difluoride membranes by contact blotting for 1 h. The apolipoprotein E isoforms were identified following immunostaining. The electrophoresis required less than 2 h and the entire procedure could be completed within 6 h.

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Severely ill patients often require total parenteral nutrition including intravenous lipid emulsions concurrently administered with lipophilic drugs. Therefore we investigated whether therapeutic application of a mixed medium chain/long chain triglyceride infusion affects the disposition of midazolam necessary for sedation in patients on artificial respiration. The concentrations of midazolam were measured in unfractionated plasma, and in lipoprotein fractions isolated from ex vivo blood samples, including determination of triglycerides and cholesterol; the albumin level was also analysed. Midazolam in the VLDL fraction was only 0.246 microgram.ml-1, whereas the total plasma concentration averaged 1.101 micrograms.ml-1, and the midazolam content of the LDL plus HDL fractions amounted to 1.771 micrograms.ml-1. Albumin in these lipoprotein fractions was just as unequally distributed. A lipid infusion resulted in a significant elevation of total triglycerides from 157 to 221 mg.dl-1 and VLDL-triglycerides from 77 to 155 mg.dl-1. The triglyceride content of the LDL plus HDL fraction rose from 102 to 139 mg.dl-1. At the same time the midazolam concentration in unfractionated plasma and in the VLDL and the LDL + HDL fractions decreased to 0.899 microgram.ml-1, 0.130 micrograms.ml-1, and 1.265 micrograms.ml-1, respectively. Cholesterol and albumin concentrations were not affected. The data show for the first time that a significant increase in plasma triglycerides during an intravenous lipid infusion does not result in accumulation of midazolam in lipoproteins, probably because albumin binding of the drug is very strong. The lack of midazolam trapping is important with respect to the safety of concurrent use of lipophilic drugs and intravenous lipid infusions.

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The relationship between coffee consumption and serum lipid levels was studied in a randomly selected sample of 395 young and 385 elderly adults in the Federal Republic of Germany. Analyses were done separately for men and women and for young and older people. After adjustment for body mass index, activity level, smoking, total energy intake, dietary fat, fish, milk, tea and alcohol consumption and oral contraceptive use a statistically significant increase in total serum- and LDL-cholesterol levels with increased coffee consumption was observed in the group of young men only. In this subgroup a difference of 0.11 mmol.l-1 serum cholesterol and of 0.10 mmol.l-1 LDL cholesterol for each additional cup of coffee consumed daily was calculated. This is one of the few studies that includes elderly people. No significant trend was seen between coffee consumption and serum- or LDL-cholesterol levels in the elderly.

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The effects of a combined exercise and low-fat dietary regimen were studied in 11 patients with angiographically documented coronary heart disease (cholesterol 233 mg/dl, triglycerides 158 mg/dl) and 13 comparable patients (cholesterol 224 mg/dl, triglycerides 174 mg/dl) on usual care. During one year, fasting serum lipoproteins were lowered to "ideal" levels in the intervention group (cholesterol 191 mg/dl, triglycerides 100 mg/dl, LDL-cholesterol 121 mg/dl). There was no change of triglycerides and cholesterol on usual care while LDL-cholesterol rose significantly. Neither regimen had any effect on HDL-cholesterol. Diurnal triglycerides as a presumptive measure of IDL in the intervention group were diminished by 39%. The study demonstrates the feasibility of a diet and exercise regimen to normalize mildly elevated plasma lipid levels and thus to possibly affect the course of coronary heart disease without drugs.

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